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9.2.1 RD1 ‐ 1 of 1 ‐ Cover Sheet.docx Revised 02/23/18
Canton City Public Health Accreditation Document Cover Sheet
Domain: 9 Standard: 9.2 Measure: 9.2.1
RD: 1 Example: 1 of 1 Dated Within: 5 years
Document Title: Quality Improvement Plan
Staff Contact: Terri Dzienis Contact Number: 330‐438‐4640
File Name: 9.2.1 RD1 – 1 of 1 – Quality Improvement Plan.pdf
Document Description: Department policy 800‐015‐P establishing a quality improvement plan
Page # Required Element
The health department must provide a quality improvement plan. The plan must address:
6 ‐ 9
Key quality terms to create a common vocabulary and a clear, consistent message.
12 ‐ 17
Key elements of the quality improvement effort’s structure
17 – 20 Types of quality improvement training available and conducted within the organization
20 ‐ 23
Project identification, alignment with strategic plan and initiation process
23 ‐ 25
Quality improvement goals, objectives and measures with time‐framed targets
26 ‐ 29
The health department’s approach to how the quality improvement plan is monitored: data are collected and analyzed, progress reported toward achieving stated goals and objectives, and actions taken to make improvements based on progress reports and ongoing data monitoring and analysis
30 ‐ 31
Regular communication of quality improvement activities conducted in the health department
31
Process to asses the effectiveness of the quality improvement plan and activities
BOARD OF HEALTH APPROVAL DATE: N/A REFERENCE NUMBER: 800‐015‐P
Quality Improvement Plan Canton City Health District SUBJECT: Quality Improvement Plan for years 2016‐2017
Applicability: All staff
TOTAL NUMBER OF PAGES: 31
REVIEW FREQUENCY: Every 2 years (Due 12/31/2017)
ORIGINAL DATE ADOPTED: 06/09/2016
LAST EFFECTIVE DATE: 06/09/2016
CONTACT PERSON & DIVISION: Terri Dzienis, APC Administrator, APC Division
FINAL
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A. APPROVAL
This document has been approved in accordance with the “800‐001‐P Standards for Writing and
Approving Policies, Procedures, Standard Operating Guidelines, and Forms” procedure as of the
effective date listed above.
B. REVISION & REVIEW HISTORY
Revision Date Review Date Person Notes on what changed
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C. TABLE OF CONTENTS
Table of Contents A. APPROVAL ................................................................................................................................................ 2
B. REVISION & REVIEW HISTORY .................................................................................................................. 2
C. TABLE OF CONTENTS ................................................................................................................................ 3
D. PURPOSE .................................................................................................................................................. 5
E. POLICY ...................................................................................................................................................... 5
F. BACKGROUND .......................................................................................................................................... 5
G. GLOSSARY OF TERMS AND ACRONYMS ................................................................................................... 5
H. CULTURE OF QUALITY .............................................................................................................................. 8
1. CURRENT STATE ................................................................................................................................ 8
2. DESIRED FUTURE STATE ........................................................................................................................ 10
I. KEY ELEMENTS OF THE QUALITY IMPROVEMENT EFFORTS STRUCTURE ................................................ 10
1. ORGANIZATIONAL STRUCTURE ............................................................................................................... 10
2. MEMBERSHIP AND ROTATION ................................................................................................................ 11
3. ROLES AND RESPONSIBILITIES ................................................................................................................. 13
4. STAFFING AND ADMINISTRATIVE SUPPORT ............................................................................................... 16
5. BUDGET AND RESOURCE ALLOCATION ..................................................................................................... 16
J. TRAINING ................................................................................................................................................. 16
1. QI TRAINING REQUIREMENTS (DESIRED FUTURE STATE) ............................................................... 16
2. ONGOING QI TRAINING .................................................................................................................. 17
3. QI TRAINING PLAN AND GOALS ...................................................................................................... 17
4. PRIOR TRAINING ............................................................................................................................. 18
K. QUALITY IMPROVEMENT PROJECTS ....................................................................................................... 19
1. IDENTIFICATION OF POTENTIAL PROJECTS ................................................................................................. 19
2. PRIORITIZATION AND SELECTION PROCESS ................................................................................................ 20
3. PROJECT INITIATION PROCESS ................................................................................................................ 20
4. PROJECT LIMITATIONS .......................................................................................................................... 21
5. PROJECT DOCUMENTATION ................................................................................................................... 21
L. QUALITY IMPROVEMENT GOALS, OBJECTIVES AND MEASURES WITH TIME‐FRAMED TARGETS ........... 22
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M. MONITORING AND EFFECTIVENESS OF THE QI PLAN AND QI ACTIVITIES ............................................. 25
1. DATA COLLECTION, MONITORING AND ANALYSIS ....................................................................................... 25
2. EFFECTIVENESS OF THE QI PLAN AND QI ACTIVITIES ...................................................................... 25
3. PROGRESS REPORTS ............................................................................................................................. 26
4. ACTIONS TAKEN TO MAKE IMPROVEMENTS .............................................................................................. 28
5. CUSTOMER / STAKEHOLDER SATISFACTION FROM SERVICES AND PROGRAMS .................................................. 28
N. REVISION AND UPDATE OF THE QI PLAN ............................................................................................... 28
O. COMMUNICATION OF QUALITY IMPROVEMENT ACTIVITIES ................................................................. 29
P. CITATIONS & REFERENCES ..................................................................................................................... 30
Q. CONTRIBUTORS ..................................................................................................................................... 30
R. APPENDICIES AND FORMS ..................................................................................................................... 30
800‐015‐01‐F: QI PROJECT PROPOSAL FORM ................................................ Error! Bookmark not defined.
800‐015‐02‐F: QI PROJECT SELECTION CRITERIA FORM ................................ Error! Bookmark not defined.
800‐015‐03‐F: QI PROJECT TEAM (QIPT) CHARTER FORM ............................. Error! Bookmark not defined.
800‐015‐04‐F: QI PROJECT WORKSHEET FORM ............................................. Error! Bookmark not defined.
800‐015‐05‐F: QI PROJECT ACTION PLAN FORM ........................................... Error! Bookmark not defined.
800‐015‐06‐F: QI PROJECT STORYBOARD FORM ........................................... Error! Bookmark not defined.
800‐015‐07‐F: QI PROJECT TEAM (QIPT) POST‐PROJECT EVALUATION FORM ............. Error! Bookmark not
defined.
800‐015‐08‐F: QI PROJECT REVIEW CRITERIA CHECKLIST .............................. Error! Bookmark not defined.
800‐015‐09‐A: QI MATURITY 10‐QUESTION SURVEY ..................................... Error! Bookmark not defined.
800‐015‐10‐A: DRAFT QUALITY IMPROVEMENT COMMITTEE TEAM CHARTER ........... Error! Bookmark not
defined.
800‐015‐11‐A: THE ABCS OF PDCA ................................................................ Error! Bookmark not defined.
800‐015‐12‐A: QUALITY IMPROVEMENT (QI) TOOLBOX ............................... Error! Bookmark not defined.
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D. PURPOSE The Canton City Health District (CCHD) is committed to the protection and improvement of the health of the residents of the City of Canton. The CCHD Quality Improvement Plan (QI Plan) serves as a key component of the overall performance improvement. The plan, along with the CCHD Strategic Plan (SP) and Workforce Development Plan (WDP), serve in synchrony to provide a framework to direct the CCHD as it moves forward in the fulfillment of its mission. E. POLICY
This QI Plan articulates the commitment to move the CCHD forward in development of a culture of
quality improvement. Leadership of the CCHD commits the necessary resources of staff time and fiscal
resources so that the workforce is prepared to execute basic quality improvement projects. In
preparation for implementation of the QI Plan, the CCHD commits to an assessment of the current
status of the CCHD workforce in terms of level of knowledge with QI principles. Our plan is to measure
this over the plan period, assessing progress on the “Roadmap to a Culture of Quality Improvement.”
Our goal is to develop a workforce with increasing skill and comfort with the implementation of QI
projects. We have established the Quality Improvement Committee (QIC) to accomplish the varying
components of the work, which consists of staff committing to serve in a role as leader and mentor with
peers and project teams (Quality Improvement Project Team ‐ QIPT). The QIPTs are expected to
encourage enthusiasm and assist in creating a shift towards establishing a culture of quality
improvement in the organization.
Identified projects are expected to align with the CCHD plans and performance management system
(PMS), which link the CCHD mission to its vision. As progress is made in skill sets of staff and leadership,
it is expected that projects will increase in scope and align with the Community Health Improvement
Plan (CHIP). All documentation of the work of teams will be placed on the CCHD shared drive, easily
accessible to staff. We aim to create an atmosphere of teamwork and transparency in the work, critical
to a shift in the culture.
F. BACKGROUND
National public health department accreditation was first available on September 14, 2011 through the
Public Health Accreditation Board (PHAB). The CCHD is committed to apply for and become an
accredited public health department through PHAB. The CCHD accreditation preparation and planning
efforts were formally initiated in January 2015 with the formation of the Accreditation Team. PHAB
standards and measures version 1.5 were made available for application starting July 1, 2014. Per PHAB
standard and measure 9.2.1, CCHD is to have established quality improvement based on organizational
policies and direction, which includes a written QI Plan. This document fulfills that standard and
measure.
G. GLOSSARY OF TERMS AND ACRONYMS
This section defines the key quality terms used by the CCHD and other terms used within this document.
Other quality related terms are located at the LeanOhio reference listed in Section P. of this document.
Administrative area project: A formal or mini QI project that involves non‐program functions, which are
typically administrative in nature. Examples: employee attendance tracking, phone call answering,
interactions with customers, etc.
BOH: Board of Health
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Community Health Improvement Plan (CHIP): Defined in PHAB measure 5.2.1L.
Customer satisfaction: Customer satisfaction is a measure of how products and services supplied by an
organization meet or surpass customer expectations. Customer satisfaction is the number of customers,
or percentage of total customers, whose reported experience with an entity, its products, or its services
(ratings) exceeds specified satisfaction goals. [Ref: Farris, Paul W.; Neil T. Bendle; Phillip E. Pfeiffer; David
J. Reibstein (2010)].
Division: Defined in section I.1.c. of this document.
Division Leader: Division leader staff are in the leadership job position over the respective division or
agency unit of the CCHD and is responsible for all activities and direction of the respective division or
agency unit. Division Leader staff include the following job positions: APC Administrator, EH Director,
Fiscal Officer, Laboratory Director, Nursing Director, and WIC Director. The Health Commissioner
position serves as the OPHI division leader.
Division Leadership Team (DLT): The Division Leader positions make up the Division Leadership Team
along with the Health Commissioner and Accreditation Coordinator (i.e. Executive Assistant). The
Division Leadership Team meets regularly to make decisions that affect the CCHD and to
review/approve new/revised policies.
Division‐specific: Involves only a single division’s activities or programs. Therefore, any changes made
will only impact the single division.
Just‐do‐it solutions: Identified problems that already have an identified solution. These problems don’t
require a team to determine the solution, so they should just be completed in accordance with section
K.1.f. of this document.
Kaizen event: An event in which QIPT members meet for five straight days or less (one business week)
to overhaul a CCHD work process identified as the topic of the QI project. The event timeframe is
designed to complete the Plan‐Do‐Check‐Act (PDCA) planning phase nonstop to ensure continuity and
efficiency. The event begins with training on the QI tools to be used. Then completing a process map of
the current state of the process, analyzing every step of the way to find all forms of waste (TIM U WOOD
tool). Then use the findings to develop a new process map that is simpler, faster, better and more cost‐
effective. At the end, action plans are developed to address all aspects of the implementation, including
training and communication. Implementation of the action plan begins as soon as the event has
concluded. [Ref: LeanOhio Bootcamp manual, 2015]
Lean: Lean refers to a collection of principles and methods that focus on the identification and
elimination of non‐value added activity (waste) involved in producing a product or delivering a service to
customers.
Mini‐QI projects: Quality improvement projects for the improvement of division‐specific processes and
only division staff are included on the team. These projects follow the procedures included in section
K.1.e. of this document.
Performance management system (PMS): The process of actively using performance data to improve
the public’s health. It includes the strategic use of performance standards, performance measures,
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progress reports and ongoing quality improvement efforts to ensure an agency achieves desired results.
[Ref: Turning Point, 2003].
Plan‐Do‐Check‐Act (PDCA): An iterative, four‐stage problem‐solving model for improving a process or
carrying out change. PDCA stems from the scientific method (hypothesize, experiment, evaluate). A
fundamental principle of PDCA is iteration. Once a hypothesis is supported or negated, executing the
cycle again will extend what one has learned. [Ref: Embracing Quality in Local Public Health: Michigan’s
QI Guidebook, 2008].
Professional staff: Professional staff include job positions that generally, but not limited to, require an
education of 4‐year college degree or higher and are assigned a pay greater than pay range four.
Professional staff includes the following job positions: APC Engineer, APC Monitoring and Inspections
(M&I) Technician, Epidemiologist, Health Services Coordinator, Project Coordinator, Project Manager,
Staff Nurse II, Staff Sanitarian I & II, WIC Breastfeeding Coordinator and WIC Dietitian.
Program area project: A formal or mini QI project that involves a single program’s functions. Program
areas per division are defined in the PMS.
QI projects or Formal QI projects: Quality improvement projects are for improvement of the CCHD
processes that involve a team of members from more than one division and that follows the procedures
included in section K. of this document.
Quality culture: QI is fully embedded into the way the agency does business, across all levels and
programs. Leadership and staff are fully committed to quality, and results of QI efforts are
communicated internally and externally. They do not assume that an intervention will be effective, but
rather they establish and quantify progress toward measurable objectives. [Ref: Roadmap to a Culture of
Quality Improvement, NACCHO, 2012].
Quality improvement (QI) (also known as continuous quality improvement): The use of a deliberate
and defined improvement process, such as Plan‐Do‐Check‐Act, which is focused on activities that are
responsive to community needs and improving population health. It refers to a continuous and ongoing
effort to achieve measurable improvements in the efficiency, effectiveness, performance,
accountability, outcomes and other indicators of quality in services or processes which achieve equity
and improve the health of the community. [Ref: Roadmap to a Culture of Quality Improvement,
NACCHO, 2012].
Quality Improvement Committee (QIC): Committee to oversee the implementation of the QI program
at the CCHD. This document discusses extensively the roles and responsibilities of this committee.
Quality Improvement Plan (QI Plan): A document (i.e. this document) which outlines how the CCHD will
conduct continuous quality improvement activities for the plan period. The plan will highlight goals, key
activities, roles and responsibilities and forms used for quality improvement‐related activities.
Quality Improvement Project Team (QIPT): Team assigned to complete QI project improvement
planning, analysis, determination and implementing. This document discusses extensively the roles and
responsibilities of the QIPT.
Quality tools (QI tools): Tools designed to assist a team when solving a defined problem or project.
Tools will help the team get a better understanding of a problem or process they are investigating or
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analyzing. Tools used by the CCHD are outlined in the appendix 800‐015‐12‐A (Quality Improvement
Toolbox) of this document. [Ref: Public Health QI Handbook, Public Health Foundation, 2012].
Roadmap: A guide that describes six key phases on a path to a QI culture, outlining common
characteristics for each phase and strategies an agency can implement to move to the next phase.
Incorporating principles of change management, the roadmap identifies these characteristics on both
the human and process aspect of change within an agency. [Ref: Roadmap to a Culture of Quality
Improvement, NACCHO, 2012].
Six Sigma: A method that provides an organization with tools to improve the capability of their business
processes. This increase in performance and decrease in process variation lead to defect reduction and
improvement in profits, employee morale and quality of products or services.
Strategic Plan (SP): Defined in PHAB measure 5.3.1A.
Supervisor: Supervisor staff includes job positions that supervise one or more employees or are
responsible for an entire program area. Supervisor staff includes the following job positions: APC M&I
Supervisor, Executive Assistant, Office Manager, Staff Nurse III, Staff Sanitarian III and WIC Dietitian III.
Support/Clerical staff: Support/Clerical staff includes job positions that generally, but not limited to,
require an education of 2‐year college degree or less and are assigned a pay equal to or less than pay
range four. Support/Clerical staff includes the following job positions: Dental Program Manager;
Laboratory Technician; Public Health Clerk I, II and PT; WIC Assistant FT and PT; and WIC Peer Helper.
Workforce Development Plan (WDP): Defined in PHAB measure 8.2.1A.
H. CULTURE OF QUALITY
1. CURRENT STATE
a) Until this time, quality improvement efforts have been limited; they have been focused on
meeting program specific measures in the divisions of the CCHD. The efforts have largely been
conducted in an isolated manner within divisions and programs and lacking integration in the
manner of reporting to the Division Leadership Team (DLT) and the Board of Health (BOH) and
lacking a framework to connect these activities to overall CCHD performance outcomes.
Examples include, post‐clinic chart audits, monitoring of immunization rates for children, the
collection of limited customer satisfaction survey data, adjustment of clinic schedules based on
customer satisfaction survey results and adjustment of processes based on staff feedback.
b) At this time, the Health Commissioner, as leader of the organization, has committed the CCHD
to develop a Quality Improvement Plan for the purposes of:
i) Formalizing a structure for reporting all QI activities currently being conducted within the
CCHD to assess the quality of services.
ii) Creating a Quality Improvement Committee (QIC) and Quality Improvement Project Teams
(QIPT) within the CCHD to implement QI initiatives.
iii) To outline the methodology for selection of QI projects within the CCHD, programs or
divisions.
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iv) To assure staff at all levels receive training in QI principles. This is also reflected in the
CCHD Workforce Development Plan (WDP).
v) To shift CCHD towards a culture of quality improvement.
c) A survey using the QI Maturity Tool (29‐question) available from OSU Center for Public Health
Practice (see reference in section P.) was conducted by Accreditation Domain 9 team staff on
October 20, 2015 to quantitatively assess the current culture of quality at the CCHD. The
following table contains a summary of the survey results:
Points received / total points possible
Culture 14 / 25 = 57%
Capacity & Competency 20 / 55 = 36%
Alignment & Spread 32 / 65 = 49%
Total 66 / 145 = 46%
The above results show that the CCHD is in the beginning of the development of a culture of
quality since it has not yet adopted formal QI projects, applied QI methods in a systematic way
or engaged in efforts to build a culture of QI.
d) The Accreditation Domain 9 team then compared the above survey results to the National
Association of County and City Health Officials (NACCHO) “Roadmap to a Culture of Quality
Improvement” (“Roadmap”), which provides guidance for qualitative assessment and placement
in development and institutionalization of continuous quality improvement. Per the Roadmap,
the CCHD is likely between Phase 1 and Phase 2 on the continuum. Using the Roadmap as
guidance, CCHD’s current culture of quality can be further summarized as the following
qualitative “Human” and “Process” characteristics:
Human Characteristics Process Characteristics
Leadership is beginning to explore and have rudimentary knowledge of QI activities, while staff are most likely without formal knowledge or understanding of QI principles.
Staff and leadership are not known to be resistant to quality improvement activities, but at this time staff in particular are simply uneducated in the language of QI and its processes.
Leadership has awareness of principles of quality assurance activities used to measure program performance, but not with the broader concepts of QI.
The CCHD is, with the creation and implementation of this QI Plan, committing to those actions required to create a culture of quality improvement.
This includes the commitment of resources, alignment of activities with the Strategic Plan, improving the capacity to collect and analyze data and to use the data as a foundation for decision‐making.
There is a commitment to move towards a more formal process for monitoring CCHD performance.
Leadership is committed to the principles of QI and recognizes its value in strengthening the overall performance of the CCHD to meet its mission.
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e) Part of the Quality Improvement Goals listed in section L. of this document is to conduct a
survey including all CCHD staff to establish baseline data on the overall CCHD developmental
status. This will be accomplished using the QI Maturity Tool (10‐question version) contained in
appendix 800‐015‐09‐A (QI Maturity 10‐Question Survey) of this document to produce
quantitative numbers and will be compared to the Roadmap for the qualitative “human” and
“process” characteristics.
2. DESIRED FUTURE STATE
a) The CCHD desires to improve its culture of quality by progressing to the next phase on the
Roadmap, which would be between Phase 2 and Phase 3. The following summarizes the
“human” and “process” characteristics of this desired future state:
Human Characteristics Process Characteristics
Select staff has received advanced QI training to serve as QIPT Consultants.
Staff time is devoted to complete QI Projects and to serve on QIC.
Provide basic QI training to all staff to improvement their knowledge.
Develop project teams for the completion of selected QI projects.
Staff are beginning to embrace QI.
Creation of the QIC to oversee the implementation of the QI program.
Use of QI model, tools and consistent documentation.
Use of data.
Reporting of QI efforts and lessons‐learned.
QI plan fully implemented, evaluated, and revised periodically.
Customer satisfaction assessment is developed and implemented, including identification of internal and external customers.
A formal performance management system is developed and implemented (contained in a separate document).
b) Using the Roadmap as guidance, the goals and activities specified in section L. of this document
are being implemented to progress toward the desired future state.
I. KEY ELEMENTS OF THE QUALITY IMPROVEMENT EFFORTS STRUCTURE
1. ORGANIZATIONAL STRUCTURE
a) As part of this initial QI plan for the CCHD, the Quality Improvement Committee (QIC) was
created to oversee the quality improvement program at the CCHD. The QIC is responsible for
overseeing and giving support in creating, maintaining and evaluating the quality improvement
efforts at the CCHD with the intent to improve the level of performance and foster a culture of
QI and excellence.
b) QI Project Teams (QIPT) will be created for each QI project selected for completion.
c) The CCHD is comprised of the following divisions/agency units, which are considered divisions
for the sake of this document. Additionally, each division has the following estimated number of
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full‐time equivalent (FTE) staff (as of 10/01/2015), to demonstrate the differences in size of the
divisions:
Air Pollution Control (APC) – 11 FTE
Environmental Health (EH) – 9.2 FTE
Laboratory (Lab) – 3 FTE
Nursing – 13.7 FTE
Office of Public Health Information (OPHI) – 2.3 FTE
Vital Statistics and Administration (VS) – 6 FTE
Women, Infants, and Children (WIC) – 10.4 FTE
d) The CCHD is comprised of the following levels of organization for the sake of this document,
which excludes seasonal staff. Additionally, each level of organization has the following
estimated number of FTE staff (as of 10/01/2015), to demonstrate the distribution of each level:
Health Commissioner – 1 FTE
Division Leader – 6 FTE
Supervisor – 7 FTE
Professional staff – 27.1 FTE
Support/Clerical staff – 14.5 FTE
e) Below is a graphic which summarizes the organizational structure of QI efforts at CCHD:
2. MEMBERSHIP AND ROTATION
a) The QIC membership shall consist of the following:
i) One member from each division, so at least six of the seven divisions are represented.
Total QIC membership shall not be less than six and not be more than seven members.
1. Since OPHI and Lab are small divisions, only one of these divisions needs to be
represented at the same time. All other divisions shall always be represented.
Board of Health
Health Commissioner
Quality Improvement Committee
QI Project
Team
QI Project
Team
QI Project
Team
QI Project
Team
All Staff
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ii) All levels of the organization shall be represented. In order to achieve that, the
membership shall consist of the following (which is based on the actual distribution of
staff listed in section I.1.d. of this document):
Not more than one (1) division leader or Health Commissioner
Not more than one (1) supervisor
Not more than three (3) professional staff
Not more than two (2) support/clerical staff
iii) Staff are qualified for membership if they meet a minimum of one of the following:
Have advanced QI skill level or will have advanced QI skill level by completing
training.
Have an interest in and aptitude for performance improvement planning, QI and/or
program evaluation.
Commit to develop and promote continuous quality improvement throughout the
CCHD.
iv) Staff become members of the QIC by recommendation and appointment by division
leaders.
v) The QIC member representing the Division Leader or Health Commissioner level of the
organization shall serve as the QIC Chairperson.
b) The QIC members shall serve a two‐year term. After two years, members may be re‐appointed
by division leaders an unlimited amount of times or division leaders may appoint a new person.
Division leaders should always consider new interested people for appointment. If a member is
unable to fulfill a two‐year term, the division leader shall appoint a replacement.
i) Note: If a QIC member that is part of an existing QIPT does not get re‐appointed they will
still remain a member of the QIPT until the completion of the project.
c) Current QIC membership is as follows:
Name Title Level Division
Terri Dzienis
APC Administrator (serves as QIC Chairperson)
Division Leader APC
Kim Koons WIC Dietician III Supervisor WIC
Kim Campbell Staff Sanitarian II Professional EH
Janet Copeland Staff Nurse II Professional Nursing
Heather Macdonald Laboratory Technician Support Lab
Debbie Mazzocca Public Health Clerk II Support VS
d) The QIPT membership shall consist of the following:
i) There shall be one QIPT formed per QI project. For concurrent projects, each QIPT shall
have separate and different members.
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ii) For projects for processes that are CCHD‐wide applicable, there should be one member
from each division, so at least four of the seven divisions are represented.
iii) For projects for program area processes (which are typically also division‐specific), the
majority of the members should be from the specific division(s) that implements the
program, with at least two additional members representing at least 2 divisions that don’t
implement the program.
iv) QIPT membership totals will vary depending on size of project. Total QIPT membership,
including the QIPT Consultant, shall not be less than five and not be more than eight
members.
v) All levels of the organization shall be represented, so at least one management (division
leader or supervisor), one professional staff and one support/clerical staff should be
members.
vi) Members are selected to fill the following needs for the QIPT:
QIPT Consultant: This person is selected from the membership of the QIC. This
person is competent in using QI tools and has advanced QI skills. This person is
responsible for scoping, preparing, and running the project. They will train team
members in the elements of QI Tools and facilitates and captures the results of the
project. This person fulfills the role of facilitator.
Fresh Perspective: Team members that have no prior knowledge of the process. This
person can give new eyes and ask insightful questions. This is a full team member
and expected to participate fully in the project. For program area projects, this
person is normally a member of another division that doesn’t implement the
program.
Subject Matter Expert: Team members that have in‐depth knowledge of the process
to be improved as part of the project.
vii) Staff become members of the QIPT by recommendation by division leaders, as
documented on appendix 800‐015‐01‐F (QI Project Proposal Form) and are approved by
the QIC as part of the QI project approval and selection process.
viii) QIPT members do not change for the entire duration of the project until the project is
completed. In the event a member cannot fulfill this term, they will not be replaced.
3. ROLES AND RESPONSIBILITIES
In order to achieve CCHD‐wide QI, all staff must be actively engaged and committed to applying QI
principles and tools to daily work. Specific roles and responsibilities are listed below:
Role Responsibility
Board of
Health (BOH)
Provide final approval of the QI Plan
Support QI efforts within the CCHD by authorizing resources for QI activities
Provide oversight and adopt policies for the CCHD
Receive reports of QI efforts from QIC Chairperson as a regular BOH meeting
agenda item
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Role Responsibility
Health
Commissioner
Provide leadership for QI efforts within the CCHD
Promote a culture of QI within the CCHD
Allocate resources for QI efforts within the CCHD
Division
Leaders
Appoint QIC member to represent division
Recommend members for QIPT
Identify staff QI training needs, as needed, and report to the QIC
Encourage staff to utilize QI concepts, tools and processes
Communicate with division staff to identify proposed QI projects
Report results of mini‐QI projects to QIC
Provide opportunity during regular division staff meetings for the QIC division
representative to report results of QI efforts to division staff
Facilitate the implementation of QI activities at the program level
Division
Leadership
Team (DLT)
Review and provide feedback of draft QI Plan received from the QIC
Approve the QI Plan
Integrate QI principles in the CCHD plans, policies and procedures
Decide which QI Projects will be posted on the CCHD website, social media
and/or PHQIX
QIC
Chairperson
Act as liaison and report activities of the QIC to the DLT and the BOH
Provide guidance and leadership to the QIC
Schedule and facilitate QIC meetings
Develop and distribute QIC meeting agendas
Approve and distribute QIC meeting minutes
Coordinate all QIC activities, including periodic QI Plan/QIC evaluations
QIC Advocate for and foster a QI culture within the CCHD
Develop and maintain the QI Plan; ensure plan meets PHAB requirements
Note: The initial 2016‐2017 QI Plan was developed by the Accreditation
Domain 9 team. All plans after this will by the responsibility of the QIC.
Evaluate, revise and update QI plan periodically
Attend and participate in scheduled QIC meetings
Assign team member to record meeting minutes
Assist in the identification, development and implementation of QI projects
Prioritize and select QI projects
Monitor and evaluate QI projects
Track and report on customer satisfaction activity
Monitor and evaluate customer satisfaction activities
Communicate progress on QI projects to staff at periodic all‐staff meetings
Communicate progress on QI projects to staff during regular division staff
meetings
Serve as QIPT consultants for QI projects, as assigned, including providing
technical assistance
Recognize individuals and teams and celebrate milestones and successes
Plan and evaluate QIC reporting and communication activities
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Role Responsibility
Evaluate and update QIC operations periodically
Identify and apply for scholarship/grants for supplemental funding sources to
use for QI activities and training
Develop QI training plan based on training needs
QI Project
Teams (QIPT)
Attend and participate in scheduled QIPT meetings and/or Kaizen events
Complete project team charter
Complete project improvement planning, analysis, determination and
implementing
Complete all necessary documentation of project improvement efforts
Report results to the QIC
Present findings/QI Project summary and lessons learned during periodic all‐
staff meetings
Use QI tools to determine root cause of issues and areas that can/should be
improved to make the process more efficient
Conduct Plan‐Do‐Check‐Act (PDCA) cycle(s), including: establishing
measurable aim, collecting and analyzing data, identifying root cause,
selecting and implementing intervention and studying results to determine
action and achieve QI project goals
Attempt to reach consensus on significant issues. If consensus cannot be
reached, majority vote prevails.
QIPT
Consultant
Provide technical assistance to develop project proposals
Provide refresher training on QI tools prior to their use during QIPT meetings
and/or Kaizen events
Provide guidance as to which tools to implement during the QIPT meetings
and/or events to ensure appropriate root cause determinations are made
Provide or sources needed technical assistance for QIPT
Assure that projects follow the PDCA process, that data is used to measure
improvement and that QI Project Worksheets and Storyboards are completed
for assigned projects
Facilitate QIPT meetings
Report progress of the project during QIC meetings periodically
All Staff Participate in QI training when offered
Develop an understanding of basic QI principles and tools through QI training
Identify areas for improvement to develop project proposals, paying
particulate interest to projects that align with strategic priorities and program
performance measures
Suggest improvement actions to address identified areas for improvement in
your division to the division leader
Apply QI principles and tools to daily work
Participate as member of the QIC and/or a QIPT as requested or required
Participate in QI projects and efforts as requested, including but not limited
to data collection, process changes and identifying areas of improvement
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4. STAFFING AND ADMINISTRATIVE SUPPORT
a) Staffing support is in the form of staff participation in the QIC and a QIPT, training and other QI
efforts. This is detailed in section I.3. of this document.
b) Administrative support staff utilized for Performance Management System (PMS) data handling
will also support QI Plan data handling for the QIC and a QIPT as needed.
5. BUDGET AND RESOURCE ALLOCATION
a) As detailed in section I.3. of this document, the resource of staff participation time in the QIC
and a QIPT, training and other QI efforts is supported by the Health Commissioner and BOH.
b) Funding necessary for providing QI training, including materials and travel expenses, is
budgeted. To keep these costs at a minimum, available scholarship/grant funding will be
pursued to use for advanced QI training and free online training tools will be used to eliminate
travel and registration expenses.
c) Funding necessary to supply project materials is provided. To keep these costs at a minimum,
standard City office supplies and/or electronic recording will be utilized as much as possible.
J. TRAINING
As part of the CCHD efforts to build a culture of quality and to continuously integrate QI, the CCHD
recognizes the need to train all employees on the principals of quality improvement. The CCHD plans to
use an incremental approach to training for this initial QI plan. The overall goal is to develop basic skills
and knowledge of QI process and to move the CCHD forward along the Roadmap during the year, as
mentioned in section H. of this document. The WDP has integrated the below specifics as to resources
and responsible parties.
Below are the desired future state QI training requirements and the training plan to progress toward
that future state
1. QI TRAINING REQUIREMENTS (DESIRED FUTURE STATE)
Training shall provide staff with a certain level of QI knowledge and skill dependent on the person’s
role in QI at the CCHD, as detailed in the table below:
Level of Skill
Role
Understanding of
the CCHD QI Plan Introduction Intermediate Advanced
New Employees X X
All existing staff X X
QIC members (that are not
QIPT Consultants) X X
QIPT Consultants (who are
also QIC members) X X X X
QIPT Members (non‐
Consultant) X X X
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Level of QI knowledge and skills are defined in the table below:
Understanding of
the CCHD QI Plan
Has read the CCHD QI Plan.
Introduction Introduction to the concept and principles of continuous QI
Intermediate Hands‐on training via work on QI project
Exposure to QI Tools: PDCA Cycle, DMAIC, SIPOC, 5 Whys, Affinity
Diagram, Impact/Control Matrix, Waste identification (TIMUWOOD),
Process Mapping, Team Charter, Action Register/Plan.
Advanced Hands‐on use of several QI tools, including but not limited to: DMAIC,
SIPOC, 5 Whys, Affinity Diagram, Impact/Control Matrix, Waste
identification (TIMUWOOD), Process Mapping, Five S, Team Charter,
Action Register/Plan, Control Chart, PDCA Cycle, Data Collection &
Analysis, AIM Statements, SMART goals.
Classroom training on Lean and/or Six Sigma subjects
2. ONGOING QI TRAINING
a) Division leaders are required to report staff training needs to the QIC in order to assess CCHD‐
wide needs and create a training plan.
b) Training records (past and current employment) and workforce development gap analysis via
the WDP will also be utilized to identify training needs and be incorporated into the training
plan.
e) Staff attendance at division staff meetings and annual all‐staff meetings receive QI updates
(lessons learned, outcomes, etc.) as ongoing training.
f) Staff receives hands‐on QI training when they participate as members of the QIC and a QIPT.
Rotating staff that are QIC and QIPT members provides more staff with that training
opportunity.
g) During QIPT meetings/events, the QIPT Consultant will provide training on the specific QI Tools
to be used by the team, prior to using the tool. This will provide knowledge to the QIPT
members so the effort using the QI tool is effective.
3. QI TRAINING PLAN AND GOALS
The following is the QI Training plan in order to achieve the desired future state QI skill level.
Training title Content Skill Level Audience Completion
Date goal
QI 101 Introduces the concept and
principles of continuous QI
and the PDCA model.
Introduction. All employees
not at skill level
including new
hires not at skill
level.
12/31/2016 for
existing and
within six
months for
new.
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Training title Content Skill Level Audience Completion
Date goal
CCHD QI Plan Review of the written
CCHD QI Plan to
understand the CCHD QI
Infrastructure and the
PDCA model.
Understanding
of the CCHD
QI Plan.
All employees
including new
hires.
10/31/2016 for
existing and
within 6
months for
new.
QI Tools
(conducted
by QIPT
Consultant)
Short summaries of QI
Tools used by QIPT teams.
Includes the following
tools: 5 Whys, SIPOC,
Affinity Diagram, Pareto
Chart, Impact/Control
Diagram, Process mapping,
Waste identification.
Intermediate. QIPT Members. Conducted
during QIPT
meetings prior
to using QI
tool. To be
completed
prior to end of
project.
LeanOhio
Boot Camp (5
days)
Comprehensive training
covering Lean and Six
Sigma concepts, QI Tools
and hands on skills.
Advanced. QIPT
Consultant, QIC
members that
want to be QIPT
Consultants and
any other
interested staff.
12/31/2017
Additional goals to complete to have a comprehensive training program have been added to the
Quality Improvement Goals listed in section L. of this document.
4. PRIOR TRAINING
The following staff completed the LeanOhio Boot Camp training prior to the approval date of this
plan and is considered having advanced QI skills.
Name Division Completion Date
Terri Dzienis APC 03/27/2015
Heather Macdonald Lab 06/03/2015
Kim Campbell EH 06/03/2015
Janet Copeland Nursing 06/17/2015
James Adams VS 12/15/2015
Amanda Archer OPHI 12/15/2015
Colton Masters EH 04/14/2016
Gus Dria EH 04/14/2016
Patty McConnell OPHI 04/14/2016
Neil DelCorso APC 05/24/2016
Ashanti Parker Nursing 06/23/2016
Christina Henning Lab 06/23/2016
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There are several existing staff with previous employment that may have provided QI training. Part
of the Quality Improvement Goals listed in section L. of this document includes the development of
an assessment to identify those employees and their level of QI skill.
K. QUALITY IMPROVEMENT PROJECTS
1. IDENTIFICATION OF POTENTIAL PROJECTS
a) Potential QI projects will be proposed based on the need to improve program processes,
objectives and/or performance measures that align with the CCHD plans and performance
management system (PMS). Potential projects may be identified in a number of ways, including,
but not limited to: identification by Division Leadership Team (DLT) and/or the QIC during
review of performance data, staff suggestions, after‐action reports (AAR), customer satisfaction
survey data, program evaluations, and audit or compliance issues, needs related to preparation
for the accreditation process, etc.
b) Other potential projects are targeted problem areas in the CCHD’s operations, or those
overarching priorities identified in the Strategic Plan (SP) or Community Health Improvement
Plan (CHIP). Consideration of national, state and local sources of benchmarks and measures,
such as the National Public Health Performance Standards, the State of Ohio Improvement
Standards and Health People 2020 goals may be used to assist in determination of priority areas
for potential QI projects.
c) Potential QI projects are submitted to the QIC for consideration on appendix 800‐015‐01‐F (QI
Project Proposal Form) of this document. QIC members are available to offer technical
assistance to staff to develop QI project proposals.
d) Staff will have the ability to make suggestions of potential projects through their division
representative on the QIC, who will help development the project proposal. Documentation for
the suggested project will be completed on appendix 800‐015‐01‐F (QI Project Proposal Form) of
this document, which will be discussed with the Division Leader, then submitted to the QIC for
consideration.
e) In addition, divisions may choose to develop quality improvement projects outside of the formal
QI project system, detailed in section K.1.a.‐d. of this document), utilizing appropriate QI tools.
These projects will be called Mini‐QI projects.
i) Mini‐QI projects are division‐specific and only division staff are included on the team. If it
is desired to have outside division staff participate on the team, a formal QI project will
need to be completed.
ii) Mini‐QI projects require the formation of a team and use of at least one QI tool for the
planning phase of the project.
iii) Mini‐QI projects require data measurement to show improvement gained.
iv) Mini‐QI projects require simpler documentation than formal QI projects (see section K.5.b.
of this document).
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v) Division leaders are responsible to ensure mini‐QI projects are aligned with the SP, CHIP,
and/or Mission, Vision, and Values. Mini‐QI projects not aligned with those shall not be
conducted.
vi) If Mini‐QI project teams develop a solution that impacts other divisions, then that project
needs to be escalated and redefined as a formal QI project.
f) In addition, divisions may have identified problems that they know the solution to fix already,
without having to implement QI tools (for example: A form in use has an error that needs fixed
to resolve processing issues). These are not projects since the solution is already known. These
also don’t involve a team to develop the solution. These are called just‐do‐it solutions, which
don’t require any formal documentation.
i) Caution: QI tools are always encouraged to be used. Someone may think they know the
solution, but after implementation of QI tools, realize another solution is more effective.
Therefore, just‐do‐it solutions should be limited to simple problems with simple solutions.
2. PRIORITIZATION AND SELECTION PROCESS
a) QIC members will discuss and decide to accept a proposal, request more information or
modifications or reject the proposal based on the appendix 800‐015‐02‐F (QI Project Selection
Criteria Form). Project proposals will have priority if they are data driven and if they are aligned
with the CCHD SP, the CHIP, program strategic plans, program evaluations, accreditation, after
action reports or customer satisfaction goals. Some accepted proposals that are prioritized
lower than other accepted proposals may be placed on a wait list.
b) All QI projects selected will be in compliance with PHAB requirements under Measure 9.2.2,
which will be projects for processes (either program area or administrative area process).
c) In order to not over use the limited resources at CCHD, the accepted proposals receiving high
priority scores will be initiated until the number of projects committed to in the QI Goals (listed
in section L. of this document) have been satisfied. Remaining accepted proposals will be placed
on a wait list until the initiated projects are completed and resources are made available again.
3. PROJECT INITIATION PROCESS
a) For each accepted QI project, a QI Project Team (QIPT) shall be formed.
i) Selection of QIPT members
1. The QIC, with the assistance of division leader recommendations, will select QI
project team (QIPT) members to ensure the criteria established in section I.2.d. of
this document is met. The QIC should consider staff to be QIPT members that have
not been members previously, so all staff can eventually have experience with
QIPTs.
2. A QIC member will be assigned by the QIC to each QIPT to serve as the QIPT
Consultant.
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ii) A QI Project Team Charter will be completed and documented using the form 800‐015‐03‐
F (QI Project Team (QIPT) Charter Form) after the team is formed as part of the Quality
Improvement Goals listed in section L. of this document.
b) The CCHD is committed to the use of the Plan‐Do‐Check‐Act (PDCA) model for quality
improvement. The QIPT are responsible to implement PDCA for their QI project either in the
form of meetings, Kaizen events or a combination of both. All CCHD staff will receive training on
this model and its use. The four stages of this model include planning an improvement, doing
(implementing) the plan, checking (or studying), which includes measurement and evaluation of
data associated with the implementation of the plan and then finally acting to adopt the change
and incorporate into standard operations, or modifying the plan and repeating the cycle until
the desired outcome is met or optimal benefit is realized. 800‐015‐11‐A The ABCs of PDCA
(Gorenflo and Moran, 2010) is provided as a supplement in which the details of this process are
explained. 800‐015‐12‐A Quality Improvement (QI) Toolbox, includes commonly used QI tools
which may be used to assist the project teams in conducting the quality improvement project
planning and evaluation portion of PDCA.
4. PROJECT LIMITATIONS
a) Due to the QI program at the CCHD being in its initial stages, QI projects will be limited in scope
to include only CCHD processes. Once the CCHDs QI Maturity and experience has increased,
larger QI projects can be tackled involving outside agencies and/or other City Departments.
b) Improvement strategies selected for projects shall be those which the CCHD has control over
(i.e. is not dependent on another City Department or outside the CCHD to implement).
c) Improvement strategies selected for projects shall incur zero additional cost for the CCHD. It is
easy to think an IT solution will solve all problems, but those typically cost money and time.
There are measurable improvements that can be realized by eliminating the waste in CCHD
processes to make them more efficient. These are the types of improvements the CCHD will be
focused on.
5. PROJECT DOCUMENTATION
a) Each QIPT is expected to document the project via 800‐015‐04‐F (QI Project Worksheet Form)
and 800‐015‐06‐F (QI Project Storyboard Form) and a summary graphic display to be shared
with all staff. At the discretion of the DLT, the project documentation may also be posted on the
CCHD website, social media and/or submitted to the Public Health Quality Improvement
Exchange (PHQIX).
i) The summary graphic display shall be a collage of pictures taken, data charts/graphs and
the like that will visually show the before and after state of the process that was
improved.
b) In addition, divisions conducting mini‐QI projects shall complete proper documentation. While
completion of a storyboard is not required for mini‐QI projects, documentation of the process,
tools used, outcomes (before and after states) and lessons learned should be completed, either
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in the form of progress notes, meeting minutes, graphic display summary or through the use of
the form 800‐015‐04‐F (QI Project Worksheet Form) by completing applicable sections.
c) Each project should have pictures taken of the initial process map with the waste marked and
the picture of the chosen improvement strategy process map, if processing mapping was used,
to show the before and after state of the process and visually show the improvement. Pictures
shall also be taken of any other QI tools implemented.
L. QUALITY IMPROVEMENT GOALS, OBJECTIVES AND MEASURES WITH TIME‐FRAMED TARGETS
The current goals were selected due to their direct correlation to advancing QI maturity of staff and
establishing culture of QI in the CCHD. The goals are specified in the table below.
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Goal/Objective/Activity Performance Measure Person(s) or Team
Responsible
Timing Target(s)
Organ
izational Culture
Conduct QI Maturity 10‐Question Survey (800‐015‐09‐
A) assessment of all staff. Then compare to the
Roadmap to determine human and process
characteristics.
Documentation of survey
and results
QIC To be completed by 08/31/2016 to
serve as baseline data then again by
12/31/2017
Develop final QIC team charter (use 800‐015‐10‐A as a
template)
Documentation of charter QIC To be completed by 08/31/2016
1. Complete QIPT charter for each QIPT; revise 800‐
015‐03‐F (QI Project Team (QIPT) Charter Form) if
necessary.
2. Develop consistent PDCA implementation
structure for QIPT meetings; revise 800‐015‐11‐A
(The ABC’s of PDCA) and 800‐015‐12‐A (Quality
Improvement Toolbox) if necessary.
Documentation of charter
and structure
QIC and QIPT
Consultants
1. QIPT charters to be completed
by 12/31/2016. Revisions
completed by 12/31/2017.
2. To be completed by 12/31/2016
with current form for trial use
and final revisions to be
completed by 12/31/2017
Cap
acity an
d Competency
Develop and implement PMS Documentation of PMS Domain 9 Team To be completed by 12/31/2016
Introductory QI training
QIC to find and select online/free intro training
Conduct intro training for all staff needed
Documentation of training QIC To be completed by 12/31/2016
QI skill assessments:
Development or select assessment
Conduct assessment of staff to determine level of
QI skill
Develop procedures for ongoing use of
assessment for new hires
Documentation of
assessment and results
QIC To be completed by 10/31/2016
Advanced QI training for QIC members at introduction
QI skill level or any other interested staff
Identify those members or staff
Apply for LGIF scholarship (if available)
Attend training (if scholarship is available)
Documentation of training QIC To be completed by 12/31/2017
QIPT training: The QIC to find online/free specific QI
Tool training modules to provide to QIPT members.
The QIC to also research and apply for grant training
Documentation of training
and grant applications (if
applicable).
QIC Grant options to be completed
by 10/31/2016
Training modules grant options
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Goal/Objective/Activity Performance Measure Person(s) or Team
Responsible
Timing Target(s)
options. to be completed by 12/31/2016
Alignmen
t & Spread
Complete one QI project in an administrative area QIPT meeting
documentation; project
documentation
QIPT selected for
project; QIC to
monitor
To be completed by 12/31/2017
Complete one QI project in a program area QIPT meeting
documentation; project
documentation
QIPT selected for
project; QIC to
monitor
To be completed by 12/31/2017
Selection of QI Projects:
1. The QIC to solicit all staff to consider submission
of QI project proposal(s)
2. QIC to select projects to fulfill goals above
1. Project proposal
documentation
2. QIC meeting
documentation; project
proposal selection
criteria documentation
1. All staff (who
are interested)
2. QIC
1. To be completed by 08/31/2016
2. To be completed by 12/31/2016
Collect the CCHD website and social media views data
to serve as baseline data
Documentation of data
collected
QIC To be completed by 08/31/2016
1. Develop at least one customer satisfaction survey.
This effort may be coordinated with the
accreditation team efforts.
2. Conduct the survey.
Documentation of Survey
form and results
QIC To be completed by 12/31/2017
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M. MONITORING AND EFFECTIVENESS OF THE QI PLAN AND QI ACTIVITIES
1. DATA COLLECTION, MONITORING AND ANALYSIS
a) The QIC will assess staff QI maturity once every two years. 800‐015‐09‐A (QI Maturity 10‐
Question Survey) consists of ten questions that represent the key domains of QI Maturity:
Organizational Culture, Capacity/Competency and Alignment and Spread.
i) The assessment is sent to all staff via free electronic survey method at the end of the
calendar year (late December) every two years.
1. Note: This initial 2016‐2017 QI plan will include sending this survey by December 31,
2017 (less than two years), then every two years thereafter.
ii) The initial baseline survey will be conducted per the timeline listed for this Quality
Improvement Goal in section L. of this document.
b) The QIC will assess the QIC progress on QI Plan goals quarterly and annually. Final assessment
will be conducted every two years as part of the QI plan cycle.
c) The QIC will review and assess all QI projects that were completed during the calendar year per
the criteria in 800‐015‐08‐F (QI Project Review Criteria Checklist) of this document at least
annually. This assessment includes the review of 800‐015‐01‐F (QI Project Proposal Form), 800‐
015‐04‐F (QI Project Worksheet Form) and 800‐015‐06‐F (QI Project Storyboard From) for the
project.
d) The QIC will review and compile the data, at least annually, of lessons learned and efficiencies
gained from the completion of QI Projects that are available on the completed 800‐015‐04‐F (QI
Project Worksheet Form), 800‐015‐06‐F (QI Project Storyboard Form) and 800‐015‐07‐F (QI
Project Team (QIPT) Post‐Project Evaluation Form).
e) The QIC will review the CCHD website views and social media post views related to QI
communication (as detailed in section N. of this document) to assess the effectiveness of this
mode of communication. This will first be done to collect baseline data and again for year‐end
data annually.
2. EFFECTIVENESS OF THE QI PLAN AND QI ACTIVITIES
a) Once every two years as part of the QI plan cycle, the QIC will discuss the effectiveness of the
QIC operations (meetings, progress reporting, tracking, etc). The QIC will determine if any
changes are needed to make improvements to better achieve the QIC objectives. The QIC Team
Charter will be updated accordingly.
b) The assessment data and results discussed in section M.1. of this document will be summarized
and compared to the targets in the table below in order to determine the effectiveness of the QI
Plan and QI activities:
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Results
Goal Measure Data Source Base 2017 Target
Organ
izational Culture Improve staff QI
maturity
Show improvement of
staff maturity
compared to baseline
Every two year QI
maturity assessment
(to be completed by
12/31/2017) compared
to 2016 baseline
assessment
TBD TBD Any increase
in maturity
Measureable success
with QI efforts
% of AIM Statement
objectives achieved in
completed QI Projects
QIC 800‐015‐08‐F (QI
Project Review Criteria
Checklist) assessment
n/a TBD 50%
Cap
acity &
Competency Complete all QI Plan
goals listed in section L.
of this document
Completion of goals by
deadlines
QIC assessment n/a TBD 100%
Completed all QI training
goals listed in section
J.3. of this document
Completion of goals by
deadlines
QIC assessment n/a TBD 100%
Alignmen
t
& Spread
Effectiveness of website
and social media
communication
strategies
Show improvement of
views
QIC assessment of
website and social
media views compared
to 2016 baseline data
TBD TBD Any increase
in views
3. PROGRESS REPORTS
a) QI projects progress
i) The QIPT Consultants will report the progress on their assigned QI projects and if they
remain on target to meet the date of completion during the regular QIC meetings. This will
be done at least quarterly.
b) QI project completion, outcomes and lessons learned
i) The QIPT are responsible to prepare the illustrative/graphic summary of their completed
project outcomes. No later than 30 days after project completion the QIPT shall post the
graphic summary in the bulletin board in the CCHD hallway.
ii) The QIPT are responsible to prepare the brief narrative written summary of their
completed project outcomes. When prompted by the Executive Assistant to provide
articles for the CCHD Annual Report, the QIC Chairperson shall promptly request the
narrative from the QIPT Consultant. The QIPT Consultant shall promptly provide narrative.
The QIC Chairperson shall provide the narrative to the Executive Assistant to include in the
Quality Improvement section of the report. The Executive Assistant is responsible to
complete the CCHD Annual Report.
iii) Each calendar quarter, the QIC will review which QI Projects are completed. If a QI Project
is completed, the QIPT Consultant will provide a written summary of their completed
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project outcomes and lessons learned and a list of staff that were part of the QIPT. The
QIC Chairperson will provide the summary to the Executive Assistant for incorporation
into the BOH Meeting packet (aka Board Report). A member of the QIC (preferably the
QIPT Consultant for the completed project) will attend the BOH meeting to discuss the
project with the BOH.
1. The QIC will develop the format of this written summary during the second calendar
quarter of implementation of this 2016‐2017 QI Plan.
iv) As soon as possible but no later than within 30 days of QI Project completion, the QIC
Chairperson will notify the DLT during one of their regularly scheduled meetings that a QI
project has been completed. The QIC Chairperson will present the project
illustrative/graphic to the DLT and the DLT will decide whether to post it on the CCHD
website and/or social media.
1. If the project will be posted to the CCHD website, the QIC Chairperson is responsible
to provide the Executive Assistant the documents and language that should be
posted to the website promptly after the DLT meeting. The Executive Assistant is
then responsible to upload the documents to the CCHD website promptly after
receipt.
2. If the project will be posted to social media, the QIC Chairperson is responsible to
provide the HAN Coordinator the documents and language that should be posted to
the social media website(s) promptly after the DLT meeting. The HAN Coordinator is
then responsible to upload/post the information to the social media website(s)
promptly after receipt.
c) QI Plan Goals progress during year
i) Each calendar quarter, the QIC will provide a written summary of the QI Plan goals
progress and if they are on target. The QIC will provide the summary to the Executive
Assistant for incorporation into the BOH Meeting packet (aka Board Report). A member of
the QIC will attend the BOH meeting to discuss the progress of the QI Plan with the BOH.
1. The QIC will develop the format of this written summary during the first calendar
quarter of implementation of this 2016‐2017 QI Plan.
ii) Each calendar quarter, the QIC Chairperson will present the same quarterly summary to
the DLT during their regular meetings.
d) QI Plan goal completion and QI effectiveness
i) Every two years at the end of the calendar year, the QIC will provide a written summary of
the QI Plan goals completion status and the QI effectiveness results to the Executive
Assistant for incorporation into the BOH meeting packet (aka Board Report). A member of
the QIC will attend the BOH meeting to discuss the goals with the BOH.
ii) The QIC Chairperson will present the same summary to the DLT during one of their regular
meetings.
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e) All CCHD staff meeting
i) Before the all CCHD staff meeting, which occurs about once per year, the QIC will prepare
the items to present during the meeting listed in section O. of this document to be shared
during the meeting. A member of the QIC will conduct the presentation during the
meeting.
4. ACTIONS TAKEN TO MAKE IMPROVEMENTS
a) During the QIC meetings, the QIPT progress and QI Plan goals progress will be discussed at least
quarterly. If the progress is not on target to meet the goals on time, the QIC will decide what
actions need to be taken, if any. These decisions will be documented in the QIC meeting
minutes.
b) As part of the QIPT completing 800‐015‐04‐F (QI Project Worksheet Form), 800‐015‐06‐F (QI
Project Storyboard Form) and 800‐015‐07‐F (QI Project Team (QIPT) Post‐Project Evaluation
Form), data will be available of the efficiencies gained and lessons learned. This data will be
used to make revisions to the QI Plan if necessary.
5. CUSTOMER / STAKEHOLDER SATISFACTION FROM SERVICES AND PROGRAMS
a) The CCHD currently has limited existing customer satisfaction surveys, which are used in the
Nursing and WIC divisions. These surveys are offered to customers periodically. The Nursing and
WIC divisions currently review the survey results, when available, and initiates mini‐QI projects
or just‐do‐it projects to implement improvements, as needed, based on the survey results.
b) The QIC will work with a program area or the Accreditation Team to develop a method and
frequency for collecting customer satisfaction data, which is one of the Quality Improvement
Goals listed in section L. of this document. This data will be utilized as part of an improvement
tool.
c) Customers/stakeholders, both internal and external, are identified on 800‐015‐04‐F (QI Project
Worksheet Form) for QI Projects. QIPT are encouraged to consider collecting data related to
customer satisfaction as part of the project process.
N. REVISION AND UPDATE OF THE QI PLAN
1. Once every two years at the end of the calendar year, the QIC will review and revise the QI Plan,
including attached forms, based on the data, evaluations and effectiveness information compiled
per section M. of this document.
a) The initial 2016‐2017 QI Plan will be reviewed by December 31, 2017 (less than two years), then
all QI Plans thereafter will be every two years.
2. The (DLT) approves the QI Plan in accordance with policy 800‐001‐P.
3. The BOH also approves the QI Plan in accordance with policy 800‐001‐P.
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a) The QIC will prepare a written summary of the plan changes to present to the BOH during the
meeting in which the QI Plan is to be approved. This summary will also be provided to the
Executive Assistant for incorporation into the BOH meeting packet.
O. COMMUNICATION OF QUALITY IMPROVEMENT ACTIVITIES
A number of methods will be used to assure regular and consistent communication of quality
improvement activities. These methods include, but are not limited to the following:
Key Message Mode of Communication Target
Audience
Frequency
Opportunities to apply
QI tools and methods
Division staff meetings
All staff meeting
All CCHD
Staff
As requested
QI Project outcomes
and lessons learned,
including recognition of
involved staff
All staff meeting All CCHD
Staff
As scheduled, about
once per year
Written report for BOH meeting
packet for the Quality
Improvement agenda line item
under reports
BOH Quarterly
QI Project outcomes –
illustrative/graphic
Bulletin board in CCHD hallway All CCHD
Staff
Within 30 days of QI
Project completion
CCHD Website
Public Within 30 days of QI
Project completion if
approved by the DLT
Social media Public At least once per year
QI Project outcomes –
brief narrative
New QI section created in written
CCHD Annual Report to include
brief narrative of QI project
outcomes
Public Annually
QI training
opportunities
Email All CCHD
Staff
When available, at
least two weeks in
advance of training
date
Progress of QI Plan
goals and objectives
DLT meetings DLT Quarterly
Written report for BOH meeting
packet for the Quality
Improvement agenda line item
under reports
BOH Quarterly
All staff meeting All CCHD
staff
As scheduled, about
once per year
QI Plan Distribute plan per policy 800‐001‐
P
All CCHD
staff and
BOH
Every 2 years
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Key Message Mode of Communication Target
Audience
Frequency
Expectation of all CCHD
staff to contribute to QI
per the QI plan
All staff meeting All CCHD
staff
As scheduled, about
once per year
QI plan distribution All CCHD
staff
Every two years
QI Plan effectiveness DLT meetings DLT Annually
Written report for BOH meeting
packet for the Quality
Improvement agenda line item
under reports
BOH Annually
All staff meeting All CCHD
staff
As scheduled, about
once per year
QIC progress QIC meeting minutes stored on
shared drive
All CCHD
staff
Updated after regular
meetings, reviewed as
desired
P. CITATIONS & REFERENCES
http://lean.ohio.gov/ (accessed various areas on 04/29/2016)
QI Maturity Tool (29‐question) from the Ohio State University (OSU) Center for Public Health Practice:
http://cph.osu.edu/practice/workforce‐development‐plan‐template (accessed “QI maturity Tool” linked
document on 10/09/2015)
National Association of County and City Health Officials (NACCHO): (2012), The Roadmap to a Culture of
Quality Improvement. Available: http://qiroadmap.org (accessed 04/29/2016).
Public Health Quality Improvement Exchange (PHQIX): www.phqix.org (accessed 04/29/2016).
Acknowledgements: The CCHD gratefully acknowledges the support of the following public health
agencies for sharing their quality improvement plans, which were utilized in the development of this
plan:
Washington County, Department of Public Health and Environment, Minnesota
Medina County Health Department, Ohio
Knox County Health Department, Illinois
Q. CONTRIBUTORS
The following staff contributed to the authorship of this document:
1. Carl Safreed, APC Engineer
2. Sharon Foster, WIC Assistant
3. Heather Macdonald, Laboratory Technician
4. Terri Dzienis, APC Administrator
R. APPENDICIES AND FORMS
800‐015‐01‐F: QI Project Proposal Form
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800‐015‐02‐F: QI Project Selection Criteria Form
800‐015‐03‐F: QI Project Team (QIPT) Charter Form
800‐015‐04‐F: QI Project Worksheet Form
800‐015‐05‐F: QI Project Action Plan Form
800‐015‐06‐F: QI Project Storyboard Form
800‐015‐07‐F: QI Project Team (QIPT) Post‐Project Evaluation Form
800‐015‐08‐F: QI Project Review Criteria Checklist
800‐015‐09‐F: QI Maturity 10‐Question Survey
800‐015‐10‐A: Draft Quality Improvement Committee Team Charter
800‐015‐11‐A: The ABCs of PDCA
800‐015‐12‐A: Quality Improvement Toolbox
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800-015-01-F: QI PROJECT PROPOSAL FORM Project Title: Submitted By:
Explain the gap in service, efficiency, or process targeted for improvement (what is the problem)?
What type of process is the project for: Administrative Program Key Project Objective(s) (what are you trying to accomplish):
Project aligns with (check all that apply): Accreditation After Action Reports Customer Satisfaction CCHD Mission, Vision, Values
CCHD Strategic Plan Community Health Improvement Plan Program Planning or Evaluation Other (specify):
Explain why this project is a priority and how it aligns with the selections above:
Has baseline data been identified to measure change? Yes No If yes, which data: Resources needed (financial, personnel and other):
List the stakeholders you plan to involve:
Who should be the QIPT Consultant of this team?
Who should be on this QI team?
Anticipated start date: Anticipated project duration: 3 mth 6 mth 9 mth 1 yr > 1 yr
QIC to Complete:
Date Submitted: QIC Review Date: Initials:
Proposal: Accepted Requesting more information or modifications Denied QIC Comments:
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800-015-02-F: QI PROJECT SELECTION CRITERIA FORM
Below are the QI Project Selection criteria to prioritize project proposals. Any item that receives an answer of “yes” shall receive a check mark. The more items that receive check marks in the boxes below indicate the proposal will receive higher priority (high priority = high quantity of check marks).
Technical:
Is it a CCHD process?
What type: Administrative Program
Is the problem that is targeted for improvement clearly defined?
Is the scope manageable?
Can it be reliably measured?
Can it be completed within the proposed timeframe?
Is data available?
Will the resources selected incur zero additional cost?
Strategic:
Is it important to several staff and/or to the community?
Specify who it is important to:____________________________________________________
Does it align with one or more of the CCHD plans?
Does the project support the CCHD mission, vision and values?
Does it have a customer focus?
Does the project have potential to be replicated across programs or have an impact on other programs/activities?
Are there no other active QI projects related to same strategic objective?
Empowerment:
Is it within the proposed QIPTs control?
Is it free from pre-conceived solutions?
Is leadership prepared to implement change?
Is there probability of success?
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800‐015‐03‐F: QI PROJECT TEAM (QIPT) CHARTER FORM
The QIPT should create this document utilizing the information on the QI Project Proposal and, if necessary, discussions with proposal submitter and/or process manager.
Charter Last Updated Date:
Project Title:
Project Objectives:
Process Manager:
Background (what is the problem, strategic importance, importance to customer):
Boundaries (limits on scope of process change allowable by Process Manager, legal restrictions, budget, etc.):
Process
Scope
First Step in the process (to be included in project):
Last Step in the process (to be included in project):
Performance Metrics: Performance Metrics Baseline
Data? (Y/N)What measures will tell you if you are successful? Current Goal
What team has authority to do:
Pilot improvement Make recommendations to process owner prior to pilot
Estimated Date of Completion:
Meeting Frequency and Duration:
Team Members:
Member Need Name Title Level Division
QIPT Consultant (also
serves as timekeeper)
Subject Matter Expert
Subject Matter Expert
Subject Matter Expert
Fresh Perspective
Fresh Perspective
Note taker/Scribe:
Other Notes about team/work:
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800-015-04-F: QI PROJECT WORKSHEET FORM Division / Program / Process Area: Program / Process Manager: Project Title:
QIPT Consultant: Project Team Members:
Project Start Date: PLAN PHASE
Describe the problem / situation / process:
Process customers / stakeholders (both internal and external):
AIM Statement (Specific, Measurable, Achievable/Action oriented, Realistic, Time Sensitive)
How will you measure improvement? What baseline data will you use?
List contributing factors and root cause(s) to the problem and describe what QI tools were used:
List potential improvement strategies and describe what QI tools were used:
Select improvement strategy and describe what QI tools were used to make decision:
Insert link to where project documents are stored, including 800-015-05-F (QI Project Action Plan Form):
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Develop and list process measures:
Develop and list outcome measures:
DO PHASE Test improvement strategy (conduct key action steps):
CHECK PHASE Study the results. What does the data indicate?
ACT PHASE Describe what action you will take:
1. Adopt the change 2. Adapt the change and repeat the cycle 3. Abandon the project
Describe the key lessons learned (two to three):
List any measure that will continue to be tracked, frequency, and who will track the measure (this will be added to the PMS):
List process efficiencies gained as a result of this implemented improvement (if any):
List the QI Tools used for this project:
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Project End Date:
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800-015-05-F: QI PROJECT ACTION PLAN FORM
Action Steps / Tasks Responsible Person(s) Target Completion Date
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800-015-06-F: QI PROJECT STORYBOARD FORM
CANTON CITY HEALTH DISTRICT – QI PROJECT SUMMARY Division / Program Area: Project Title: Team: Project Start and End Dates:
PLAN 6. Develop Process & Outcome Measures
ACT 1. Describe the Problem 9. Adopt, Adapt or Abandon
2. Define the AIM DO
7. Test Improvement Strategy (Conduct key action steps)
10. Describe Lessons Learned
3. Identify Baseline Data
4. List Potential Improvement Strategies CHECK 8. Study the Results
11. Identify On-going Measures
5. Select Improvement Strategy
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800-015-07-F_QI PROJECT TEAM (QIPT) POST-PROJECT EVALUATION FORM.doc Rev: 06/09
800-015-07-F: QI PROJECT TEAM (QIPT) POST-PROJECT EVALUATION FORM To be completed by all QIPT members within 30 days after the project completion.
Describe the degree of the QI process that you learned:
Describe your perceived contribution to the project:
Describe the value of the project experience and ultimate outcome:
Describe lessons that you learned specifically:
Your suggestions to improve the QIPT experience:
Your suggestions to improve the overall CCHD QI efforts:
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800-015-08-F: QI PROJECT REVIEW CRITERIA CHECKLIST Below are the QI Project review criteria to evaluate projects. Any item that receives an answer of “yes” shall receive a check mark. The more items that receive check marks in the boxes below indicate the project will receive higher review score. QI Project Initiation and Status:
Has a draft AIM statement been developed that is specific, time-sensitive and measurable? Has data been identified to measure improvement? Has the PDCA model been outlined to date on the QI Project Worksheet? Does the project have an action plan with timelines? Does the project appear to be on schedule? Is pilot-testing part of the plan? Was baseline data collected? Will data be available to measure improvement? Have QI tools been used? Are there opportunities to use additional QI tools in the PDCA model?
What are the technical assistance needs at this point? Specify:____________________________________________________________________________
What are the project successes to date and current challenges? Specify:____________________________________________________________________________
Projects Nearing Completion
Are the strategies appropriate without revision? If require revision, specify:________________________________________________________
Is no additional testing needed? If additional testing needed, specify:________________________________________________
Does the data indicate improvement? If yes to the above, is the team satisfied with the level of improvement?
Completed QI Projects
Has the project been outlined on the QI Project Storyboard Form (800-015-06-F)? Has the project been summarized in a illustrative/graphic display? Did the project accomplish the primary goals it set out to achieve? Has the target within the AIM Statement been achieved? Did the project stay within the limitations (see section K.4. of the QI Plan)? Have opportunities for follow-up (continued activity or measurement) been identified with
timelines? Are there opportunities to replicate the project elsewhere in CCHD and/or the City?
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800-015-09-F: QI MATURITY 10-QUESTION SURVEY
Organizational QI Maturity 10-Question Survey The questions on this survey are drawn from a QI maturity survey developed to evaluate the Robert Wood Johnson Foundation Multi-State Learning Collaborative (MLC)1. This select set of ten questions was developed by the Minnesota Public Health Research to Action Network to represent the key domains of QI maturity.
Organizational Culture Strongly
Agree Agree Neutral Disagree Strongly Disagree
I don’t know
1. Staff members are routinely asked to contribute to decisions at my public health agency.
2. When trying to facilitate change, staff has the authority to work within and across program boundaries.
3. The key decision makers in my agency believe quality improvement is very important.
4. My public health agency currently has a pervasive culture that focuses on continuous quality improvement.
Capacity / Competency Strongly
Agree Agree Neutral Disagree Strongly Disagree
I don’t know
5. The leaders of my public health agency are trained in basic methods for evaluating and improving quality, such as Plan-Do-Check-Act.
6. My public health agency has a Quality Improvement Plan.
7. My public health agency currently has a high level of capacity to engage in quality improvement efforts.
Alignment and Spread Strongly
Agree Agree Neutral Disagree Strongly Disagree
I don’t know
8. Job descriptions for many individuals responsible for programs and services at my public health agency include specific responsibilities related to measuring and improving quality.
9. Customer satisfaction information is routinely used by many individuals responsible for programs and services in my public health agency.
10. My public health agency currently has aligned our commitment to quality with most of our efforts, policies and plans.
1Joly, B.M., Booth, M., Mittal P., & Shaler, G. Measuring quality improvement in public health: the development and psychometric testing of a QI Maturity Tool. Eval Health Prof., 35(2):119-47.
For more information on this tool: www.health.state.mn.us
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800-015-10-A: DRAFT QUALITY IMPROVEMENT COMMITTEE TEAM CHARTER
Charge As part of the continuous quality improvement and performance management system, the Quality Improvement Committee (QIC) exists to oversee and support continuous quality improvement efforts, QI projects, QI training, customer satisfaction and performance/QI-related communications.
Primary Goals • assure measureable CCHD success with quality improvement efforts • improve staff capacity to engage in quality improvement efforts • use customer feedback for improvement planning • implement effective performance communications strategies • make the use of quality improvement tools and techniques user friendly, participatory and part
of daily work
Primary Activities • prioritize and select QI projects • monitor and evaluate QI projects • provide and/or source technical assistance for QI projects • assist in the identification, development and implementation of QI Projects • recognize individuals and teams and celebrate milestones and successes • select, coordinate and evaluate staff quality improvement training • develop QI training plan based on training needs • identify and apply for scholarship/grants for supplemental funding sources to use for QI
activities and training. • plan and evaluate QIC reporting and communications activities • track and report on customer satisfaction activity • monitor and evaluate customer satisfaction activities • evaluate and update QIC operations periodically • advocate for and foster a QI culture within the CCHD • develop and maintain the QI Plan; ensure plan meets PHAB requirements • evaluate, revise and update QI plan periodically • communicate progress on QI projects to staff at periodic all-staff meeting
Composition/Membership One member from each division, so at least six of the seven divisions are represented. [Note: Since OPHI and Lab are small divisions, only one of these divisions needs to be represented at the same time. All other divisions shall always be represented.] Total membership shall not be less than six and not be more than seven members.
All levels of the organization shall be represented. In order to achieve that, the membership shall consist of the following:
• Not more than one (1) division leader or Health Commissioner • Not more than one (1) supervisor • Not more than three (3) professional staff
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• Not more than two (2) clerical/support staff
The QIC member representing the division leader or Health Commissioner level of the organization shall serve as the QIC Chairperson.
Appointment to the QIC Staff becomes members of the QIC by recommendation and appointment by division leaders
Term Members shall serve a two-year term. After two years, members may be re-appointed by division leaders an unlimited amount of times or division leaders may appoint a new person. Division leaders should always consider new interested people for appointment. If a member is unable to fulfill a two-year term, the division leader shall appoint a replacement. [Note: If a member that is part of an existing QIPT does not get re-appointed, they will still remain a member of the QIPT]
Membership Criteria Staff are qualified for membership if they meet a minimum of one of the following:
• Have completed or will complete advanced QI training • Have an interest in and aptitude for performance improvement planning, QI and/or program
evaluation • Commit to develop and promote continuous quality improvement throughout CCHD.
Roles and Duties
Role Duties Chairperson • Provide guidance and leadership to the QIC
• Develop and distribute meeting agendas • Approve meeting minutes; save on share drive and notify members • Facilitate meetings • Coordinate all QIC operations • Schedule meeting rooms and equipment • Provide member orientation • Act as liaison and report activities of the QIC to the DLT and BOH
Note Taker This position rotates monthly among all members other than Chairperson. • Take minutes during meetings • Draft minutes on the share drive; notify Chairperson
Members • Attend and participate in scheduled QIC meetings • Complete required work between meetings • Assign team member to record meeting minutes • Actively learn about QI • Promote QI to other staff • Complete respective assignments, as determined by the QI Plan and QIC decisions • Serve as QIPT Consultants for QI projects, as assigned • Communicate progress on QI projects to staff at periodic all-staff meeting • Communicate progress on QI projects to staff during regular division staff
meetings
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Role Duties QIPT Consultants
• Provide technical assistance to develop project proposals • Provide refresher training on QI tools prior to their use during QIPT meetings • Provide guidance as to which tools to implement during the QIPT meetings to
ensure appropriate root cause determinations are made • Provide or sources needed technical assistance for QI project teams (QIPT) • Assure that projects follow the PDCA process, that data is used to measure
improvement and that QI Project Worksheets and Storyboards are completed for assigned projects
• Facilitate QIPT meetings. • Report progress of the project during QIC meetings at least quarterly.
Voting QIC members will attempt to reach a consensus on significant issues. If consensus cannot be reached, majority vote prevails. Voting can only occur if a quorum is present. A quorum is four out of six members or five out of seven members, depending on the size of the QIC.
Meetings Meetings are held monthly for ninety (90) minutes, on the second (2nd) Monday of the month, from 1:30-3:00 pm.
Time Commitment The maximum time commitment for QIC members is anticipated to be three to five hours per month. This includes meetings and meeting preparation time.
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800-015-11-A: THE ABCS OF PDCA
The ABCs of PDCA Grace Gorenflo and John W. Moran1
The Public Health Accreditation Board's (PHAB) voluntary accreditation program emphasizes the importance of quality improvement, and has catalyzed health department activity in this arena. The Accreditation Coalition, comprising national public health leaders, defines quality improvement in public health as the following:
"Quality improvement in public health is the use of a deliberate and defined improvement process, such as Plan-Do-Check-Act, which is focused on activities that are responsive to community needs and improving population health. It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community. "2
The Plan-Do-Check-Act cycle (PDCA) has been embraced as an excellent foundation for, and foray into, quality improvement for public health departments, as it is both simple and powerful. Its simplicity comes from the systematic, straightforward and flexible approach that it offers. Its power is derived from its reliance on the scientific method, i.e., it involves developing, testing, and analyzing hypotheses. This foundation offers a means to become comfortable with a host of quality improvement methods and techniques, and to progressively evolve into addressing more complex problems, employing additional QI tools, and migrating to system-wide approaches to QI. PDCA is based on the "Shewhart cycle," and was made popular by Dr. W. Edwards Deming, considered by many to be the father of modem quality control.3 During his lectures in Japan in the early 1950s, Deming noted that the Japanese participants shortened the cycle's steps to the now traditional plan, do, check and act. It is interesting to note that Deming preferred plan, do, study, and act because the translation of "study" from Japanese to English has connotations closer to Shewhart's intent than does "check."4 This model has been around for 60 years and it is relevant in today's public health world, providing a defined and well tested process to achieve lasting improvement to the problems and challenges public health is now facing. Spending adequate time in each phase of the PDCA cycle is imperative to having a smooth and meaningful quality improvement process. The elements put forth here comprise a deliberate process based on the scientific method, and help ensure that improvement efforts are conducted in a way that will maximize the degree of success achieved. Before beginning the PDCA process, it is important to assemble the team that will participate and to develop a communications plan about the effort. Assemble the team PDCA involves a team approach to problem solving. To begin, designate a team leader and team members, and address the following questions:
Do we have the right people (i.e., those who are directly involved with the area needing improvement)? Does the team need training?
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Who will facilitate the team and process? Another key step is to develop a team charter5, which serves to provide focus and clarity regarding the team's work. Additional resources on tending to teams as they move through the PDCA process may prove useful to optimize the team's performance.6 Communication plan Those involved with or impacted by improvements must be kept informed of the changes, timing, and status of the quality improvement project. It's important to establish a communication plan at the outset of the improvement effort, and to communicate and post progress on a regular basis, in a highly visible location, for all to see. Storyboards7 offer a cogent picture of key points in the PDCA cycle, and can be an effective venue to tell the story as the team moves through its improvement work. Phases of the PDCA Model The phases of the PDCA model below assume that just one underlying, or root cause will be addressed by testing just one intervention. When undertaking the PDCA process, the team may decide to address more than one root cause, and/or to test more than one intervention to address a root cause. In such instances, it will be important to measure the effect of each intervention on the root cause it is intended to address. Plan: The purpose of this phase is to investigate the current situation, fully understand the nature of any problem to be solved, and to develop potential solutions to the problem that will be tested.
1. Identify and prioritize quality improvement opportunities. Usually a team will find that there are several problems, or quality improvement opportunities, that arise when programs or processes are investigated. A prioritization matrix8 may help in determining which one to select. Once the quality improvement opportunity has been decided, articulate a problem statement. Revisit and, as appropriate, revise the problem statement as you move through the planning process.
2. Develop an AIM statement9 that answers the following questions:
a. What are you seeking to accomplish? b. Who is the target population? c. What is the specific, numeric measure(s) you are seeking to achieve? d. The measurable improvement objective is a key component of the entire quality
improvement process. It's critical to quantify the improvement you are seeking to achieve. Moreover, the entire aim statement also will need to be revisited and refined as you move through the planning phase.
3. Describe the current process surrounding the problem in order to understand the process and identify areas for improvements. Flow charts and value stream mapping are two examples of methods to accomplish this.
4. Collect data on the current process. Baseline data that describe the current state are critical to
further understanding the process and establishing a foundation for measuring improvements. The data may address, for example, time, people, space, cost, number of steps, adverse events, and customer satisfaction. A host of tools are available to collect and interpret data on the
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process, such as Pareto charts, histograms, run charts, scatter plots and control charts. The data collected must be aligned with the measures listed in the aim statement.
5. Identify all possible causes of the problem and determine the root cause. While numerous
causes will emerge when examining the quality improvement opportunity, it is critical to delve in and carefully identify the underlying, or root cause of the problem, in order to ensure that an improvement or intervention with the greatest chance of success is selected. Brainstorming is a useful way to identify possible causes and a cause and effect/fishbone diagram and the 5 Whys are useful for determining the actual root cause.
6. Identify potential improvements to address the root cause, and agree on which one to test. Once the improvement has been determined, carefully consider any unintended consequences that may emerge as a result of the implementing improvement. This step provides an opportunity to alter the improvement and/or develop countermeasures as needed to address any potential unintended consequences. Revisiting the aim statement and revising the measurable improvement objectives are important steps at this point.
7. Develop an improvement theory. An improvement theory10 is a statement that articulates the
effect that you expect the improvement to have on the problem. Writing an improvement theory crystallizes what you expect to achieve as a result of your intervention, and documents the connection between the improvement you plan to test and the measurable improvement objective.
8. Develop an action plan indicating what needs to be done, who is responsible, and when it
should be completed. The details of this plan should include all aspects of the method to test the improvements - what data will be collected, how frequently data are collected, who collects the data, how they are documented, the timeline, and how results will be analyzed.
Do: The purpose of this phase is to implement the action plan.
1. Implement the improvement.
2. Collect and document the data.
3. Document problems, unexpected observations, lessons learned and knowledge gained. Check/Study: This phase involves analyzing the effect of the intervention. Compare the new data to the baseline data to determine whether an improvement was achieved, and whether the measures in the aim statement were met. Pareto charts, histograms, run charts, scatter plots, control charts and radar charts are all tools that can assist with this analysis.
1. Reflect on the analysis, and consider any additional information that emerged as well. Compare the results of your test against the measurable objective.
2. Document lessons learned, knowledge gained, and any surprising results that emerged. Act: This phase marks the culmination of the planning, testing, and analysis regarding whether the desired improvement was achieved as articulated in the aim statement, and the purpose is to act upon what has been learned. Options include:
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1. Adopt: Standardize the improvement if the measurable objective in the aim statement has been met. This involves establishing a mechanism for those performing the new process to measure and monitor benchmarks on a regular basis to ensure that improvements are maintained. Run charts or control charts are two examples of tools to monitor performance.
2. Adapt: The team may decide to repeat the test, gather different data, revise the intervention, or
otherwise adjust the test methodology. This might occur, for example, if sufficient data weren't gathered, circumstances have changed (e.g., staffing, resources, policy, environment, etc.), or if the test results fell somewhat short of the measurable improvement goal. In this case, adapt the action plan as needed and repeat the "Do" phase.
3. Abandon: If the changes made to the process did not result in an improvement, consider lessons
learned from the initial test, and return to the "Plan" phase. At this point the team might revisit potential solutions that were not initially selected, or delve back into a root cause analysis to see if additional underlying causes can be uncovered, or even reconsider the aim statement to see if it's realistic. Whatever the starting point, the team will then need to engage in the Plan cycle to develop a new action plan, and move through the remaining phases.
PDCA offers a data-based framework based on the scientific method. This simple yet powerful format drives continuous and ongoing efforts to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community. Please direct any comments on this article to Grace Gorenflo at [email protected] or John Moran [email protected].
References: 1 Grace Gorenflo is Director, Accreditation Preparation and Quality Improvement, NACCHO and John W. Moran is Senior Quality Advisor to the Public Health Foundation and a Senior Fellow at the University of Minnesota School of Public Health in the Division of Health Policy and Management 2 This definition was developed by the Accreditation Coalition Workgroup (Les Beitsch, Ron Bialek, Abby Cofsky, Liza Corso, Jack Moran, William Riley, and Pamela Russo) and approved by the Accreditation Coalition on June 2009. 3 http://en.wikipedia.org/wiki/PDCA - accessed 12/2/2009 4 http://en.wikipedia.org/wiki/PDCA - accessed 12/2/2009 5 J. Moran and G. Duffy. Team Chartering. Quality Texas Newsletter, April 10, 2010 (available at www.naccho.org/toolbox/ in the Quality Improvement Toolkit) 6 Team Assessment, team charter, team manager self-assessment, team process review checklist, and T. Kuras and J. Moran. 20 Questions to Ask Your Team. The Quality Management Forum, Winter Edition, Vol. 23, Number 4, 1997 are all available at http://www.naccho.org/toolbox/ in the Quality Improvement Toolkit 7 A number of national efforts to support QI in public health have used a storyboard format that was developed by the Michigan department of public health and can be accessed at http://nnphi.org/CMSuploads/Storyboard-Guidelines-FINAL-05868.pdf (accessed 3/26/10) 8 Bialek, R., Duffy, G. L., Moran, J. W. (2009). The Public Health Quality Improvement Handbook. Milwaukee, WI: ASQ Quality Press. This resource contains all of the quality improvement tools mentioned in this paper. 9 http://www.accreditation.localhealth.net/MLC-2%20website/Michigans QI Guidebook.pdf – accessed 3/26/10 10 Ibid.
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800-015-12-A: QUALITY IMPROVEMENT (QI) TOOLBOX
The complete LeanOhio Tool Kit is available at the following website link: http://lean.ohio.gov/resources.aspx
Below is a list of commonly used QI Tools:
a. Flow charting: Use of a diagram in which graphic symbols depict the nature and flow of the steps in a process. This tool is particularly useful in the early stages of a project to help the team understand how the process currently works. The “as-is” flow chart may be compared to how the process is intended to work. At the end of the project, the team may want to then re-plot the modified process to show how the redefined process should occur. The benefits of a flow chart are that it:
1) Is a pictorial representation that promotes understanding of the process? 2) Is a potential training tool for employees? 3) Clearly shows where problem areas and processes for improvement are.
Flow charting allows the team to identify the actual flow-of-event sequence in a process.
b. Brainstorming: A tool used by teams to bring out the ideas of each individual and present them in an orderly fashion to the rest of the team. Essential to brainstorming is to provide an environment free of criticism. Team members generate issues and agree to “defer judgement” on the relative value of each idea. Brainstorming is used when one wants to generate a large number of ideas about issues to tackle, possible causes, approaches to use or actions to take. The advantages of brainstorming are that it:
1) Encourages creativity. 2) Rapidly produces a large number of ideas. 3) Equalizes involvement by all team members. 4) Fosters a sense of ownership in the final decision as all members actively participate. 5) Provides input to other tools: “brain stormed” ideas can be put into an affinity diagram or they
can be reduced by multi-voting.
Process
Decision
Document
Data
Predefined process
Preparation
Terminator
FLOW CHART SYMBOLS
Yes
No
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UndesiredOutcome
POLICIES &PROCEDURES(PROCESSES)
SUPPLIES,EQUIPMENT &
MATERIALS
CAUSE & EFFECT DIAGRAM
PHYSICALENVIRONMENT
OTHERAREAS
Security problems
Unsafe conditions
No policies present
conflicting policies
Insufficient supplies
HumanResources
Human Error
Staffing
Competency
inadequate policies
not available
c. Decision-making tools: While not all decisions are made by teams, two tools can be helpful when teams need to make decisions.
1) Multi-voting is a group decision-making technique used to reduce a long list of items to a manageable number by means of a structured series of votes. The result is a short list identifying what is important to the team. Multi-voting is used to reduce a long list of ideas and assign priorities quickly with a high degree of team agreement.
2) Nominal Group technique-used to identify and rank issues.
d. Affinity Diagram: The Affinity Diagram is often used to group ideas generated by brainstorming. It is a tool that gathers large amounts of language data (ideas, issues, opinions) and organizes them into groupings based on their natural relationship. The affinity process is a good way to get people who work on a creative level to address difficult, confusing, unknown or disorganized issues. The affinity process is formalized in a graphic representation called an Affinity Diagram. This process is useful to:
1) Sift through large volumes of data. 2) Encourage new patterns of thinking.
As a rule of thumb, if less than 15 items of information have been identified; the affinity process is not needed.
e. Cause and Effect Diagram (also called a fishbone or Ishakawa diagram): This is a tool that helps identify, sort and display. It is a graphic representation of the relationship between a given outcome and all the factors that influence the outcome. This tool helps to identify the basic root causes of a problem. The structure of the diagram helps team members think in a very systematic way. The benefits of a cause-and-effect diagram are that it:
1) Helps the team to determine the root causes of a problem or quality characteristic using a structured approach.
2) Encourages group participation and utilizes group knowledge of the process. 3) Uses an orderly, easy-to-read format to diagram cause-and-effect relationships. 4) Indicates possible causes of variation in a process. 5) Increases knowledge of the process. 6) Identifies areas where data should be collected for additional study.
Cause and effect diagrams allow the team to identify and graphically
display all possible causes related to a process, procedure or system
failure.
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f. Histogram: This is a vertical bar chart which depicts the distribution of a data set at a single point in time. A histogram facilitates the display of a large set of measurements presented in a table, showing where the majority of values fall in a measurement scale and the amount of variation. The histogram is used in the following situations:
1) To graphically represent a large data set by adding specification limits one can compare; 2) To process results and readily determine if a current process was able to produce positive
results assist with decision-making.
g. Pareto Chart: Named after the Pareto Principle which indicates that 80% of the trouble comes from 20% of the problems. It is a series of bars on a graph, arranged in descending order of frequency. The height of each bar reflects the frequency of an item. Pareto charts are useful throughout the performance improvement process - helping to identify which problems need further study, which causes to address first and which are the “biggest problems.” Benefits and advantages include:
1) Focus on most important factors and help to build consensus. 2) Allows for allocation of limited resources.
The “Pareto Principle” says 20% of the source causes 80% of the problem. Pareto charts allow the team to graphically focus on the areas and issues where the greatest opportunities to improve performance exists.
h. Run Chart: Most basic tool to show how a process performs over time. Data points are plotted in temporal order on a line graph. Run charts are most effectively used to assess and achieve process stability by graphically depicting signals of variation. A run chart can help to determine whether or not a process is stable, consistent and predictable. Simple statistics such as median and range may also be displayed. The run chart is most helpful in:
1) Understanding variation in process performance. 2) Monitoring process performance over time to detect signals of change. 3) Depicting how a process performed over time, including variation.
Allows the team to see changes in performance over time. The diagram can include a trend line to identify possible changes in performance.
Event Rate - 12 Months
0
2
4
6
8
14/7 30/8 14/8 15/6 14/4 30/7 30/6 14/2 30/5 22/4
Wards
Ra
te/P
ati
en
t
60%
65%
70%
75%
80%
85%
90%
Perc
ent
Com
plia
nce
2nd QTR 973rd QTR 97
4th QTR 971st QTR 98
2nd QTR 983rd QTR 98
4th QTR 981st QTR 99
2ND QTR 993RD QTR 99
4th QTR 99
Quarters
RUN CHART
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i. Control Chart: A control chart is a statistical tool used to distinguish between variation in a process resulting from common causes and variation resulting from special causes. It is noted that there is variation in every process, some the result of causes not normally present in the process (special cause variation). Common cause variation is variation that results simply from the numerous, ever-present differences in the process. Control charts can help to maintain stability in a process by depicting when a process may be affected by special causes. The consistency of a process is usually characterized by showing if data fall within control limits based on plus or minus specific standard deviations from the center line. Control charts are used to:
1) Monitor process variation over time. 2) Help to differentiate between special and common cause variation. 3) Assess the effectiveness of change on a process. 4) Illustrate how a process performed during a specific period.
j. Bench Marking: A benchmark is a point of reference by which something can be measured, compared or judged. It can be an industry standard against which a program indicator is monitored and found to be above, below or comparable to the benchmark.
k. Root Cause Analysis: A root cause analysis is a systematic process for identifying the most basic factors/causes that underlie variation in performance. A common root cause analysis approach is the 5 Whys. To use the 5 whys, you do the following:
1) Once you have identified a problem, ask the question “Why did this problem occur?” There may be multiple answers to that question.
2) Then take each of the answers and ask the question again. 3) Continue to do this until you have uncovered the possible root causes of the problem. It may be
necessary to ask “why” several times (about five) before you uncover the root causes.
Using upper control limits (UCLs) and lower control limits (LCLs) that are statistically computed, the team can identify statistically significant changes in performance. This information can be used to identify opportunities to improve performance or measure the effectiveness of a change in a process, procedure, or system.
65%
70%
75%
80%
85%
90%
Per
cent
Com
plia
nce
2nd QTR 973rd QTR 97
4th QTR 971st QTR 98
2nd QTR 983rd QTR 98
4th QTR 981st QTR 99
2ND QTR 993RD QTR 99
4th QTR 99
Quarters
Pilgrim Psychiatric Center Control Chart
UCL
LCL
0 0.5
1 1.5
2 2.5
3 3.5
Months
F 11 Month Statewide A